In a report analysing more than 200 complaints about NHS mental health care Behrens highlighted “failings that have occurred, and continue to occur, in specialist mental health services in England, and the devastating toll this takes on patients and their families”.

The report identifies five “common failings” by mental health trusts that can lead to patients suffering distress or harm or dying avoidably. They include inadequate assessment of the patient’s risk of suffering harm or committing suicide and poor communication between health professionals and the patient or their family.

The report is a dossier of detailed but anonymous cases which, in some cases, led the ombudsman to conclude that patients were subjected to care so poor that it was “injustice [that was] shocking and tragic”. The failings illustrate how far the NHS has to go if it is to improve care in the dramatic way that ministers and health service bosses have promised in recent years.

For example, a Ms J died after she had a life-threatening reaction, called neuroleptic malignant syndrome (NMS), to being prescribed an antipsychotic drug for a psychotic episode she was having. Doctors dismissed the physical symptoms of her condition.

“Had doctors identified NMS, it is likely that Ms J would have received the appropriate treatment and survived. As such, we concluded that Ms J’s death was avoidable,” the report said. Her death illustrated “the human cost of service failures”, Behrens said.

In another case, a mental health professional decided that a Mr O was suffering from an episode of psychosis for the first time. However, the worker breached National Institute of Health and Care Excellence guidelines by not assessing the patient for signs of post-traumatic stress disorder. The NHS trust’s risk assessment “was too brief and inadequate”, the report said.

“It is shocking but unsurprising to hear of so many times where services failed to provide even the basics in terms of offering the right treatment, operating safely or treating people with dignity and respect,” said Sophie Corlett, director of external relations at Mind, the mental health charity.

“This report exposes some alarming care failings,” said Prof Wendy Burn, the president of the Royal College of Psychiatrists. She urged ministers to ensure that NHS mental health services had enough money to do their jobs properly. “Unfortunately, our latest research shows mental health trusts’ income is lower than it was in 2012.”

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Although the cases relate to “systemic failings” that occured before 2016, when the NHS agreed to overhaul mental health care through the Five Year Forward View for Mental Health, the same sorts of failings are still happening, said Behrens.

Understaffing of NHS mental health services is a key reason, he added. For example, the number of mental health nurses fell 13% between 2009 and 2017, and England’s 53 mental health trusts are short of about 10% of staff.

NHS mental health trusts upheld 65% of 14,106 written complaints they received in 2016-17, higher than the 61% upheld by acute (physical) health trusts. For that reporting year, the ombudsman investigated 352 complaints about mental health trusts, upholding 37%, compared to 40% for acute trusts.

• This article was amended on 21 March 2018. An earlier version referred to complaints against NHS mental health trusts in 2016-17 that were upheld by the ombudsman. Those figures related to complaints received by NHS mental health trusts themselves.